Nursing Home Survey on Patient Safety Culture

2008 Preliminary Comparative Results

Preliminary comparative results are provided for the items and safety culture dimensions on the AHRQ Nursing Home Survey on Patient Safety Culture to allow nursing homes to compare their survey results against the results from 40 nursing homes that participated in a pilot test of the survey in the United States in late 2007 and early 2008.

 Contents

Purpose and Use of this Document
Overview
Survey Background
Description of the 40 Pilot Study Nursing Homes
Description of Nursing Home Pilot Study Respondents
Item-Level Comparative Results
Composite-Level Comparative Results
Composite Percent Positive Scores
 

Purpose and Use of this Document

Preliminary comparative results are provided for the items and safety culture dimensions on the AHRQ Nursing Home Survey on Patient Safety Culture to allow nursing homes to compare their survey results against the results from 40 nursing homes that participated in a pilot test of the survey in the United States in late 2007 and early 2008.

Note: When comparing your nursing home's results against the comparative results provided in this document, keep in mind that these results are from limited numbers of staff and nursing homes and will provide only a general indication of how your nursing home compares with other nursing homes in the United States.

At this time, there is no central repository for nursing homes to submit data for benchmarking purposes. However, similar to the AHRQ Hospital Survey on Patient Safety Culture Comparative Database (http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/index.html), AHRQ plans to support an annual U.S. comparative database on the nursing home survey that will provide more extensive comparative data. More details will be forthcoming from AHRQ about when data submission will begin and when the new comparative results will be available.

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Overview

  • Preliminary comparative data are provided for the survey items and for composite scores on the safety culture dimensions based on pilot data obtained from 3,698 staff from 40 nursing homes.
  • Basic descriptive data are provided about the respondents and nursing homes that participated in the pilot study.
  • This document also contains a description of how to calculate your nursing home's composite scores on the Nursing Home Survey on Patient Safety Culture.

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Survey Background

The Nursing Home Survey on Patient Safety Culture is an expansion of AHRQ's Hospital Survey on Patient Safety Culture, which was pilot tested and made available to the public in November 2004 (http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/index.html). The Nursing Home Survey on Patient Safety Culture was specifically designed to measure the culture of resident safety in nursing homes from a staff perspective.

Safety culture can be defined as the set of values, beliefs, and norms about what is important, how to behave, and what attitudes are appropriate regarding patient safety in a work group or organization. The Nursing Home Survey on Patient Safety Culture is intended to help a nursing home assess the extent to which its organization's culture emphasizes the importance of resident safety, facilitates open discussion and teamwork, and creates an atmosphere of continuous learning.

The survey design team reviewed the literature on resident safety problems and issues in nursing homes; interviewed more than two dozen long-term care experts, researchers, nursing home administrators, and staff to identify appropriate survey topics; and drafted sets of survey dimensions and items for review by experts. The subsequent draft was pretested with nursing home staff to ensure that the questions were easy to understand and answer and that the items were relevant. The pilot test survey was then administered in 40 nursing homes. The data were analyzed, the psychometric properties of the survey (reliability and factor structure) were examined, and the length was shortened by dropping items. The final version of the Nursing Home Survey on Patient Safety Culture is below a 6th-grade reading level.

The final survey includes 42 survey items that measure the following 12 areas of organizational culture pertaining to resident safety:

  1. Communication openness.
  2. Compliance with procedures.
  3. Feedback and communication about incidents.
  4. Handoffs.
  5. Management support for resident safety.
  6. Nonpunitive response to mistakes.
  7. Organizational learning.
  8. Overall perceptions of resident safety.
  9. Staffing.
  10. Supervisor expectations and actions promoting resident safety.
  11. Teamwork.
  12. Training and skills.

The survey uses either 5-point frequency scales ("Never" to "Always") or 5-point agreement scales ("Strongly disagree" to "Strongly agree"). Most items include a "Does not apply or Don't know" option.

The survey also includes two overall rating questions that ask respondents to indicate whether they would tell friends the nursing home was safe for their family and to provide an overall rating on resident safety. The last section of the survey asks respondents to write any comments they have about resident care and safety in their nursing home.

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Description of the 40 Pilot Study Nursing Homes

The nursing home survey was pilot tested with staff and physicians from 40 nursing homes in the United States from late 2007 to early 2008. Nursing homes varied by bed size, urbanicity, ownership, and geographic region, but the nursing homes that voluntarily participated in the pilot study were not a statistically representative sample of all nursing homes in the United States.

Tables 1 to 5 show overall statistics about the participating nursing homes and respondent characteristics. A few highlights about the pilot study nursing homes are:

  • 85 percent of the nursing homes had between 51 and 199 beds.
  • Nearly two-thirds of the 40 nursing homes were located in an urban area.
  • Nursing homes were equally distributed between for profit and not for profit.
  • Almost half of the nursing homes were located in the South; only 8 percent were in the West.

Note: Column percent totals in the tables may not sum to exactly 100 percent because of rounding of decimals.

Table 1. Overall statistics for participating nursing homes1

Overall StatisticNumber
Total number of participating nursing homes40
Total number of individual survey respondents3,698
Total number of surveys administered5,065
Overall response rate73%
Average number of completed surveys per nursing home
(range: 23 to 233 surveys)
92
Average number of surveys administered per nursing home
(range: 55 to 292 surveys)
134
Overall average response rate72%

 

Table 2. Distribution of pilot study nursing homes and respondents by bed size

Bed Size2008 Pilot Study
Nursing Homes
2008 Pilot Study
Respondents
NumberPercentNumberPercent
≤50 beds25%702%
51-99 beds1640%1,14431%
100-199 beds1845%1,75547%
200 or more beds410%72920%
TOTAL40100%3,698100%

 

Table 3. Distribution of pilot study nursing homes and respondents by urbanicity

Urbanicity2008 Pilot Study
Nursing Homes
2008 Pilot Study
Respondents
NumberPercentNumberPercent
Urban2665%2,76575%
Rural1435%93325%
TOTAL40100%3,698100%

 

Table 4. Distribution of pilot study nursing homes and respondents by ownership

Ownership and Control2008 Pilot Study
Nursing Homes
2008 Pilot Study
Respondents
NumberPercentNumberPercent
For profit2050%1,81949%
Not for profit2050%1,87951%
TOTAL40100%3,698100%

 

Table 5. Distribution of pilot study nursing homes and respondents by region

Census Bureau Region2008 Pilot Study
Nursing Homes
2008 Pilot Study
Respondents
NumberPercentNumberPercent
South1948%1,71046%
Northeast1025%1,15031%
Midwest820%64117%
West38%1975%
TOTAL40101%3,69899%

Note: States are categorized into Census Bureau regions as follows:
South: AL, AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV
Northeast: CT, ME, MA, NH, NJ, NY, PA, RI, VT
Midwest: IL, IN, IA, KS, MI, MN, MS, NE, ND, OH, SD, WI
West: AK, AZ, CA, CO, HI, ID, NM, MT, UT, NV, OR, WA, WY

1 Most of the pilot test nursing home points of contact received remuneration to help promote the survey and encourage response and most individual nursing home staff received $5 prepaid cash as an incentive to complete the pilot survey. Therefore, pilot test response rates reported here are likely to be higher than those obtained in nursing homes where no monetary incentives are provided.

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Description of Nursing Home Pilot Study Respondents

Tables 6 to 8 illustrate the distributions of respondents across work areas/units, interaction with residents, and staff position.

Note: Individuals who did not respond to a question are shown as missing in the following tables and are excluded from total percentages. Column percent totals in the tables may not add to exactly 100 percent because of rounding of decimals.

Table 6. Distribution of respondents by work area/unit: Pilot study nursing homes

1321/1321

Work Area/UnitAll Pilot Study Respondents
NumberPercent
Many different areas in this nursing home/
No specific area or unit
1,32142%
Other area or unit79325%
Skilled nursing unit57918%
Alzheimer's/Dementia unit2418%
Rehab unit2207%
TOTAL3,154100%
Missing: No answer544 
Overall total3,698 

 

Table 7. Distribution of respondents by interaction with residents: Pilot study nursing homes

Respondent Interaction With ResidentsAll Pilot Study Respondents
NumberPercent
YES, I work directly with residents most of the time2,26269%
NO, I do NOT work directly with residents most of the time1,00731%
TOTAL3,269100%
Missing: No answer or question was not asked429 
Overall total3,698 

 

Table 8. Distribution of respondents by staff position: Pilot study nursing homes

Staff PositionAll Pilot Study Respondents
NumberPercent
Nursing Assistant/Aide1,03433%
Support Staff64920%
Licensed Nurse53117%
Administrator/Manager32810%
Direct Care Staff30210%
Administrative Support Staff1725%
Other1154%
Physician (MD, DO)311%
Other Provider171%
TOTAL3,179101%
Missing: No answer519 
Overall total3,698 

Respondents in the overall pilot study also reported the following workplace characteristics:

Tenure in current nursing home

  • 6 years or more—41%.
  • 3 to 5 years—22%.
  • 1 to 2 years—20%.
  • Less than a year—nearly 18%.

Usual hours worked per week

  • Less than 25 hours per week—14%.
  • 25 to 40 hours per week—60%.
  • More than 40 hours per week—26%.

Shift worked most often

  • Day shift—73%.
  • Evening shift—18%.
  • Night shift—10%.

Staffing agency status

  • Paid by a staffing agency—6%.

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Item-Level Comparative Results

To compare your nursing home's results on any item from the Nursing Home Survey on Patient Safety Culture, you first need to calculate your nursing home's percentage of positive response on each item. 

  • For positively worded items, this means simply calculating the total percentage of respondents who answered positively (combined percentage of "Strongly agree" and "Agree" responses, or the "Always" and "Most of the time" responses, depending on the response categories used for the item).
  • For negatively worded items, calculate the total percentage of respondents who answered negatively (combined percentage of "Strongly disagree" and "Disagree" responses, or "Never" and "Rarely" responses, since a negative answer on these items indicates a positive response).

 

Once you have calculated your nursing home's percentage of positive response on each item, compare your item-level results with the average percentage of positive response from the 40 pilot test nursing homes, shown in Chart 1. Chart 1 also shows the minimum score from the lowest scoring nursing home and the maximum score from the highest scoring nursing home for each survey item.

  • Use a difference of 5 percentage points as a rule of thumb when comparing your medical office's results to the comparative results. Your nursing home's percentages should be at least 5 points higher than the comparative results to be considered "better" (e.g., 75% vs. 70%) and should be at least 5 points lower to be considered "lower" than the comparative results (e.g., 60% vs. 65%).
  • Keep in mind that this information provides only relative comparisons. Even though you may find your nursing home's results are better than the comparative results, you may still believe there is room for improvement in an absolute sense.

Chart 2 shows the distribution of responses to the Recommendation question. Chart 3 shows the distribution of responses to the Resident Safety Rating question.

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Composite-Level Comparative Results

In addition to comparing your nursing home's results on each item, you can obtain a summary view of how your nursing home compares to other nursing homes by examining composite scores. A composite score summarizes how respondents answered groups of items that all measure the same thing. Composite scores on the 12 patient safety culture survey dimensions tell you the average percentage of respondents who answered positively when looking at the survey items that measure each safety culture dimension. Composite scores allow a summary comparison because you compare against only 12 safety culture dimensions rather than 42 separate survey items.

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Composite Percent Positive Scores

To calculate your nursing home's composite score on a particular safety culture dimension, simply average the percent positive response on each item that is included in the composite. Here is an example of computing a composite score for Staffing:

  1. There are four items in this composite—two are positively worded (items A3 and A16) and two are negatively worded items (items A8 and A17). Keep in mind that DISAGREEING with a negatively worded item indicates a POSITIVE response.

  2. Calculate the percent positive response at the item level (see example in Table 9).

Table 9. Example of How To Calculate Item and Composite Percent Positive Scores

Four items measuring "Staffing"For positively worded items, the # of "Strongly agree" or "Agree" responsesFor negatively worded items, the # of "Strongly disagree" or "Disagree" responsesTotal # of responses to the item (excluding NA/DK & missing responses)Percent positive response on item
Item A3-positively worded:
"We have enough staff to handle the workload"120NA*260120/260=46%
Item A16-positively worded:
"Residents' needs are met during shift changes"130NA*250130/250=52%
Item A8-negatively worded:
"Staff have to hurry because they have too much work to do"NA*110240110/240=46%
Item A17-negatively worded:
"It is hard to keep residents safe here because so many staff quit their jobs"NA*140250140/250= 56%
* NA = Not applicableAverage percent positive response across the 4 items = 50%

In this example, there were four items, with percent positive response scores of 46 percent, 52 percent, 46 percent, and 56 percent. Averaging these item-level percent positive scores (46% + 52% + 46% + 56% / 4 = 50%) results in a composite score of .50 or 50 percent on Staffing. That is, an average of about 50 percent of the respondents responded positively on the survey items in this composite.

  • Use a difference of 5 percentage points as a rule of thumb when comparing your medical office's results to the comparative results. Your nursing home's percentages should be at least 5 points higher than the comparative results to be considered "better" (e.g., 75% vs. 70%) and should be at least 5 points lower to be considered "lower" than the comparative results (e.g., 60% vs. 65%).
  • Keep in mind that this information provides only relative comparisons. Even though you may find your nursing home's results are better than the comparative results, you may still believe there is room for improvement in an absolute sense.

 

Chart 4 shows the average percent positive response from the 40 pilot study nursing homes on each of the survey's patient safety culture composites, in order from most positive to least positive. The minimum score from the lowest scoring nursing home and the maximum score from the highest scoring nursing home are also shown for each composite.

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Produced by Westat under contract for the Agency for Healthcare Research and Quality (AHRQ)

Current as of November 2008
Internet Citation: Nursing Home Survey on Patient Safety Culture: 2008 Preliminary Comparative Results. November 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/nursing-home/2008/index.html